?: I think the standard at these meetings -- we have to see them as kind of informal meetings. "Meeting the experts" -- so that is meeting. That means that here are some people who have experience, but more people on your side who have more experience. So I would say that after shared introductions and presentations we will take it over to you to find a dialogue. What does it mean, street outreach? I would invite you to focus on three issues: what is the experience until now, what can be learned from that, and what will be our next policy; next steps. Do you go on in the same way, or is it really necessary to change how we do it?

Before I give the floor to the speakers, I just want to introduce myself quickly. I'm Franz [?]. I'm working for a Dutch agency. We support AIDS problems in the developing countries. We've been doing that for ten years, and we do have a lot of experience, through those programs, with street outreach work in Latin America, Africa and, unfortunately, also it is common more in Asia, India, and other countries. But I will now give the floor to Ann [?]. Ann is a nurse administrator from British Columbia, here in Canada, and has a long [?] nursing experience from the hospital and [?] to community mental health. She has experience since 19[?] administration [?] frontline work.

Ann: Thank you, Franz. Can you hear me? I have to have my notes in front of me, 'cause I always get nervous at these sorts of things. But my understanding of these sessions is that they are supposed to be very interactive. I was really intimidated when I was invited to come to this session as an expert, because there's a lot of expertise out there. And I mostly attribute that expertise to the clientele that we see in our program.

What I'd like to do is give you a short rundown of the program as it exists here in Vancouver, to give you a little context of what my experience is, and then pass you along to Paulo, and then hopefully open the floor for questions. So I want to give you some quick views on health promotion and harm reduction from the perspective of the street nurse program. Because these form the foundation for our street outreach strategies and interventions. We regard harm reduction as an integral part of health promotion. Health promotion being, as defined by the WHO, the process of enabling people to increase control over and to improve their health. Or, to phrase it another way, the ethical provision of health care; a continuum of client-centred services.

Such care delivery places a high value on the inherent worth of the individual and his or her right to self-determination. If we accept this, we assist others to further their self-determined goals, while at the same time reducing or avoiding harm. Reducing fear for clients, care providers and the community must be a major consideration. To be effective, we must be willing to share knowledge with and provide clients with information, tools and access to appropriate services, or to advocate for such services if they don't exist. And most experience has been that the needed services are lacking.

The goal of the street nurse program is to reduce HIV transmission, in particular with the street-involved population of Vancouver. We operate three storefront clinics in areas of Vancouver where our clientele are most concentrated. In addition to the nine community nurses in the program, we have two health-care workers who liaise with and provide services to the South Asian and Hispanic populations. We visit clients in the local jails and detoxes. We meet clients on the street, either on foot or through mobile outreach, five nights a week, in our van. Staff on the van provide health care and educational backup to the Vancouver Needle Exchange van during their nightly rounds as well. We deliver education and direct health care on the street. We attempt to give clients what they need: user-friendly, accessible services at no cost to them. A safe place to verbalize their feelings, fears and hopes.

On the streets, we seek to meet our clients in their territory. Our immediate goal is risk reduction, and we carry needles to exchange and condoms for distribution. Our longer-term goal is to establish trust with our clients so that they will eventually choose to come to us with their concerns. These are clients who, for the most part, aren't connected with the health care system. Whose trust is often hard-won and requires an investment of time and patience. We may see a client a few times on the street before we even approach them. This gives them time to become familiar with our faces and perhaps ask their peers who we are and what we're about.

When we do approach them, we are clear that we're on their turf, and are respectful of that. We'll introduce ourselves and our service, offer condoms and needles, and perhaps leave it at that. Any more might be seen as intrusive, or cause the client to become suspicious of our motives. It might take a number of encounters before we get a name -- if clients choose to give us a name; we don't care -- let alone any idea of their risks and concerns. All the while we try to make our good intentions clear and keep our encounters short, consistent and respectful.

With our established clientele, street encounters can be as simple as a quick greeting, distributing a few condoms, and maybe exchanging a couple of needles. It could be changing a dressing on an abscess or administering Narcan to a client who's overdosed on heroin. Given our clients' general reluctance to seek out traditional health care facilities, we often encounter health care concerns that would probably have gone unattended if we hadn't met them on the street. We'll either treat them on the spot, or accompany the client to one of our clinics or to another health care provider, depending on the nature of the concerns.

Clients' basic needs and rights to stable housing, nutrition, health care and safety must be taken into account. The priority of daily needs often outweighs the importance of taking measures to improve health and prevent disease. Isolation, fear, violence, language and cultural differences, and limited education or employment options are further obstacles to overcome.

In the early days of our program, prostitution was concentrated in a few areas in this city. Since the inception of "Shame the john" type campaigns, sex trade workers have regularly and systematically been shifted out of neighbourhoods. The result has been a scattering throughout the city of various pockets where prostitutes work. These are always moving, depending on the tolerance and attitudes of the communities where they choose to locate.

To respond to this demand, we have expanded our mobile outreach. Five nights a week, staff drive the streets, identifying areas where sex trade workers are located, and offer condoms, needle exchange and an introduction to our services. We have identified a number of shooting galleries, where we've become known and trusted by the clients. We exchange needles, offer [?] maintenance education and often respond to minor concerns, such as dressing an abscess, or major concerns, such as arranging admission to hospital for endocarditis or extensive cellulitis.

There are dynamic, ever-changing needs presented to us in the street nurse program. As new clients make their way to the street, they seek to find their own way and place in that community. This constantly presents us with new challenges: to identify the client and their particular needs, and strive to deliver an effective, accessible, acceptable service based on those needs.

There are opportunities to share knowledge, and a willingness to explore our own and our clients' values and beliefs -- including their relationship to drugs. These are important considerations in order to help clients come to well informed, self-determined goals -- goals that are rooted in their own realities. Inclusion of clients and their affected communities should not be overlooked when developing program strategies and specific outreach interventions. They are the experts. Peer education can promote a possible change in the client's social structure. Flexibility and innovation, advocacy and support, planning and evaluation are all necessary program components.

I have a few other comments -- which I think I will make after the next speaker, when we get into the question and discussion period -- about some important considerations in establishing or setting up outreach programs.

Thank you.

MC: Is it wise to ask you, because you said you had some comments after the presentation of Paulo, that we do it then? That we give Paulo the floor now? I think it is better, because then we can combine those two things.

Paulo Longo has a long time experience working in AIDS fields in Brazil, particularly in Rio de Janeiro, where he himself has worked as a street outreach worker for quite a long time. He now coordinates a program on it. He said to us in the beginning that he, not he but the organization, is desperately looking for support, so funders in this room, listen. Paulo please...